Dying at Home Often Easier on Cancer Patients, Caregivers

MONDAY Sept. 13, 2010 -- For people with advanced cancer, dying at home rather than the hospital results in higher quality-of-life scores at the end of life, and may be easier on the patients' caregivers as well.

A study published online Sept. 13 in the Journal of Clinical Oncology found that compared to people who died in intensive care units (ICU) or other areas of a hospital, when people died at home, their loved ones were less likely to develop post-traumatic stress disorder or prolonged grief disorder, marked by intense, disabling grief that goes on longer than six months.

"Where someone dies has important implications for those they leave behind," said the study's lead author, Dr. Alexi Wright, an instructor in medicine at Harvard Medical School and the Dana-Farber Cancer Institute in Boston.

"It's really important for people to articulate what they want. Dying at home may improve your own quality of life before death and it may improve your loved ones' grief after your death," she noted.

While most cancer patients prefer to die at home, that's not always what happens, according to background information in the study. More than one-third of cancer patients die in the hospital and 8 percent die in the intensive care unit. Almost one-quarter of Medicare costs stem from intensive care treatment during the last month of life, according to the study.

To get an idea of whether the location where death occurs is associated with a better quality of life for patients at the end of life, and whether or not the place of death affects caregivers, Wright and her colleagues recruited 342 terminal cancer patients and their primary caregivers.

The cancer patients were interviewed at the start of the study, which was a median time of about 4.5 months before they died. Their caregivers were also interviewed when the study began and then around two weeks after the death of their loved one to discuss the quality of life experienced by their loved one at the end of life. In addition, the bereaved caregivers were also interviewed 6 months later.

The researchers found that people who died in the ICU or other areas of the hospital had more physical and emotional distress at the end of their lives, and had a poorer quality of life, compared to those who died at home with hospice care.

And, those who died at home appeared to have more well-adjusted loved ones after the death, reported the study.

"The place of death and the amount of medical treatment received shaped the bereavement experience. There was a fivefold increase in post-traumatic stress disorder in people whose loved ones died in the ICU versus at home," said Wright. "While people may think that dying at home might be more frightening for caregivers, it may ultimately help them heal."

Wright's group also found that the risk of prolonged grief disorder among those whose loved ones died in the hospital was much higher -- almost 22 percent compared to 5.2 percent among caregivers whose loved ones died with home hospice.

Wright said the differences may stem from the activities that may take place in the hospital or ICU before death, due to the frightening nature of aggressive lifesaving care, such as cardiopulmonary resuscitation or mechanical breathing devices.

"This study wasn't surprising. If patients and family members are in a familiar and comfortable environment, they'll likely have a better outcome in terms of quality of life," said Dr. Steven Libutti, director of the Montefiore-Einstein Center for Cancer Care in New York City. "A clearly unanswered question, though, is how do we decide when we've reached the end of our likely successful therapies? When do you come to an acceptance that you've exhausted all reasonable possibilities and transition to end-of-life care?"

Other experts stress that quality of life is an essential measure.

"Making the quality of life better for a patient with a terminal diagnosis is often more valuable than attempting to get an extension of life at the cost of quality," said Wright.